Atrial fibrillation Flashcards
How may a patient with AF present?
Palpitations
Shortness of breath
Syncope - dizzy or fainting
Symptoms of associated conditions e.g. stroke, sepsis, thyrotoxicosis
How will AF look on an ECG?
Absent P waves
Narrow QRS complex tachycardia
Irregularly irregular ventricular rhythm
What other arrhythmia can display an irregularly irregular pulse, other than AF?
Ventricular ectopics
These disappear when heart rate gets over certain threshold e.g. during exercises, therefore, a regular heart rate during exercises suggests ventricular ectopics
When should rhythm control therapy be offered to AF patient?
When should rate control therapy be given?
There is reversible cause for their AF
Their AF is of new onset (within last 48 hours)
Their AF is causing heart failure
They remain symptomatic despite being effectively rate controlled
If none of the above is met, then 1st line is RATE CONTROL
What options are available for rate control therapy in AF?
Rate control:
1st line = Beta-blocker (e.g. atenolol) or Calcium channel blocker (e.g. diltiazem)(contraindicated in HF)
Digoxin - only in sedentary people, needs monitoring and risk of toxicity
If mono therapy not adequate, combine any of the 1st line option with beta-blocker, diltiazem or digoxin
What options are available for rhythm control therapy in AF?
Immediate cardioversion given to AF patients that present less than 48 hrs or are severely haemodynamically unstable
Delayed cardioversion given to AF patients that present more than 48 hrs and are stable. Here, you should anticoagulate patient for minimum of 3 weeks and give rate control therapy whilst waiting for cardioversion
2 options for cardioversion: pharmacological or electrical
Pharmacological cardioversion 1st line = flecanide (if no structural heart disease) or amiodarone
Electrical cardioversion uses a defibrillator to restore to sinus rhythm
What is the “pill in pocket” drug of choice in patients with paroxysmal AF?
Flecanide
Why should flecanide be avoided in atrial flutter?
It can cause 1:1 AV conduction and result in significant tachycardia
What scoring tool is used to determine the most appropriate anticoagulation strategy?
CHA2DS2-VASc
score of 0 = no treatment but ensure transthoracic echo has been done to exclude valvular heart disease, which in combination with AF is an absolute indication for anticoagulation
score of 1 = if male consider anticoagulation, if female no treatment
score of >1 = offer anticoagulation
What anticoagulation is offered to patients with AF?
Warfarin:
Has half life of 1-3 days
Reversed with vitamin K
NOACs e.g. Apixaban, dabigatran, rivaroxaban:
Apixaban and dabigatran are taken BD, rivaroxaban is taken OD
NOACs have 7-15 hour half life so they reverse themselves quite quickly.
For rapid reversal, idarucizumab can be used for dabigatran, and andexanet alfa can be used for apixaban and rivaroxaban
